Provider Demographics
NPI:1447416235
Name:KENNEDY, NICHOLAS DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:DAVID
Last Name:KENNEDY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67-1125 MAMALAHOA HWY
Mailing Address - Street 2:
Mailing Address - City:KAMUELA
Mailing Address - State:HI
Mailing Address - Zip Code:96743-8496
Mailing Address - Country:US
Mailing Address - Phone:808-881-4880
Mailing Address - Fax:
Practice Address - Street 1:67-1125 MAMALAHOA HWY
Practice Address - Street 2:
Practice Address - City:KAMUELA
Practice Address - State:HI
Practice Address - Zip Code:96743-8496
Practice Address - Country:US
Practice Address - Phone:808-881-4880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-01
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1250516442085R0202X
HIMD-229482085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology